Provider Demographics
NPI:1699787440
Name:MOORE, MEREDITH ANNE (LBSW)
Entity type:Individual
Prefix:
First Name:MEREDITH
Middle Name:ANNE
Last Name:MOORE
Suffix:
Gender:F
Credentials:LBSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3847 PINE GROVE AVE STE A
Mailing Address - Street 2:
Mailing Address - City:FORT GRATIOT
Mailing Address - State:MI
Mailing Address - Zip Code:48059-4265
Mailing Address - Country:US
Mailing Address - Phone:810-966-3734
Mailing Address - Fax:
Practice Address - Street 1:3847 PINE GROVE AVE STE A
Practice Address - Street 2:
Practice Address - City:FORT GRATIOT
Practice Address - State:MI
Practice Address - Zip Code:48059-4265
Practice Address - Country:US
Practice Address - Phone:810-966-3734
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802084415104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker